Condom distribution and HIV education

Adherence support for children and their caregivers

Issues spotlighted

ARV tender and upcoming TB tender

Gender based violence

TAC Districts

TAC has six district offices in six provinces and a national office. TAC's campaigns improve health outcomes and access to HIV and TB treatment, prevention and care. The knowledge and experience gained in our districts informs national advocacy efforts.

Below is a map of TAC districts that are referred to in this report.

World AIDS Day 2010

The year’s final quarter began with the commemoration of World AIDS Day on December 1st. Deputy President and chair of the South African National AIDS Council (SANAC), Kgalema Motlanthe, honoured this year’s World AIDS Day by visiting Mkhondo municipality in Gert Sibande, Mpumalanga.

Prior to World AIDS Day, the Treatment Action Campaign (TAC) in Gert Sibande mobilised community members to take part in the event through door-to-door campaigns. The event was attended by over 6000 members of the community. Tents were set up for community members to get tested for HIV and TB and to apply for ID documents, birth certificates and social grants.

Motlanthe updated spectators on progress implementing the updated HIV treatment and prevention policies announced on World AIDS Day 2009. He said that access to antiretroviral therapy (ART) had been expanded to over 1 million people, 3,126 nurses had been trained to initiate treatment and HIV counselling and testing had been provided to more than 4.68 million people.

However, despite these important successes, South Africa is still falling short of the targets laid out in the country’s National Strategic Plan (NSP) 2007-2011 and the period for achieving these targets is drawing to a close.

Motlanthe announced that reviews of the NSP 2007 - 2011 and consultations in preparation for the NSP 2012 -2016 are to be held. The new NSP is to be launched on World AIDS Day 2011.

TAC has committed to participating in these reviews and in the development of the next NSP through SANAC and through provincial and district AIDS councils. During March and April, TAC will carry out district reviews on the NSP and identify priorities for the next NSP. The outcomes of these reviews will be featured in the next NSP report (March – May 2011).

Outside of Gert Sibande, TAC staff and members also commemorated World AIDS Day talking to the media and giving presentations in offices, schools, universities and communities. TAC Khayelitsha’s members were treated to a special performance of Zip Zap circus featuring performances by Ibhongolwethu and Zip Zap kids. The Ibhongolwethu Project run by Zip Zap and Medicins Sans Frontiers teaches circus arts to children living with HIV.

In Pretoria TAC partnered with SECTION27, COSATU and others on World AIDS Day to demand the release of Chinese AIDS activist Tian Xi and other human rights activists detained in China. Tian Xi is a Chinese AIDS activist who has been detained, without a formal sentence, since August 6, 2010. He was detained because of his campaign to petition the Chinese government to compensate him and thousands of others infected with HIV via China's blood supply.

TAC and partner organisations marched to the Chinese Embassy in Pretoria where a petition was delivered to the Chinese Ambassador calling for the immediate release of Tian Xi and many others who are in prison for their attempts to defend and promote human rights.

Deputy President Kgalema Mothlante in Gert Sibande for World AIDS Day

World AIDS Day in Gert Sibande

State of healthcare in the districts

Implementation of the new guidelines - challenges and successes

TAC’s policy, communication and research staff report quarterly on the challenges and successes of HIV prevention and treatment programmes in their districts. The information below is a compilation of these reports.

During this quarter TAC Lusikisiki and TAC Ekurhuleni both reported that patients were receiving treatment on time, at average CD4 counts of 200. However TAC Gert Sibande, Mopani and uMgungundlovu reported that patients are only receiving antiretroviral treatment (ART) at CD4 counts below 200. TAC Gert Sibande carried out a survey that found the average CD4 count at initiation to be 120. TAC Gert Sibande was able to assess this figure with the assistance of clinic data managers, the figure was rounded off from facilities capturing data electronically.

Under South Africa’s guidelines pregnant women and people co-infected with TB must be initiated on ART at CD4 counts of 350, all other patients must wait for their CD4 counts to fall to 200 before initiating treatment. Delaying treatment until CD4 counts drop below 200 fails to meet the World Health Organisation recommendation of initiating at counts of 350. These delays in initiation increase the risk of opportunistic infections and onward transmission of HIV.

Districts reported that while facilities experienced stock-outs of both lamivudine and emtracitabine, patients were only dispensed two of the three drugs used in a first line ART regimen.

TAC Gert Sibande found that the stockouts were due to shortages of staff and lack of training. Because of this staff lacked capacity to monitor medicines supplies and order sufficient medicines.

As reported last quarter, more patients are now being dispensed with more than one month’s supply of ART at a time. Only patients in Lusikisiki and uMgungundlovu are not yet offered more than 1 month of treatment at a time. Healthcare workers in uMgungundlovu and Mopani continued to cite fears that dispensing more than one month of ART could lead to poor adherence.

The only challenge reported in relation to the new provision of prevention-of-mother to child transmission guidelines have been the ongoing stockouts of formula milk. These stockouts could lead to mixed-feeding and thereby increase the risk of transmission. We also note that formula milk has been completely removed as an option for mothers in KwaZulu-Natal.

Voluntary medical male circumcision (VMMC) is now available in all six provinces where TAC has district offices. However, facilities providing this service remain limited. In Mopani men seeking VMMC must still pay user fees.

The shortages of female condoms reported in previous publications have been ongoing in all districts monitored by TAC.

Over this quarter, government continued to accredit more facilities to provide ART, continued to implement nurse initiated and managed ART, and scaled up community-healthcare-worker-provided HIV Counselling and Testing.

The Eastern Cape reported on its success since April 2010 during a meeting of the provincial AIDS council. At the beginning of the HCT campaign only 85 facilities were initiating ART. The province set a target for an additional 755 facilities to be assessed for accreditation by June 2011. At the end of February 2011, 517 facilities were assessed with 318 now providing ART.

The province also reported that 622 nurses were trained to initiate and manage ART. With a serious shortage of healthcare workers, Lusikisiki was the first TAC district to implement nurse initiated treatment and community health care worker testing in all facilities.

Community healthcare workers continue to be trained to provide finger prick HIV tests, as part of government’s task-shifting initiatives to address the human resource shortage. Community healthcare workers are providing tests in all facilities in Gert Sibande, Mopani and Lusikisiki but the shortage of human resources and space continues to be a challenge. TAC Mopani reported that one facility stopped providing HIV counselling and testing when the community healthcare worker in that facility went on maternity leave. Community healthcare workers are providing testing in only two facilities in Ekurhuleni.

uMgungundlovu continues to lag behind other provinces on task-shifting, with no nurses initiating and managing ART or community healthcare workers providing testing.

All districts report that the shortage of human resources continues to be a major challenge. The shortage of space and lack of infrastructure also undermines the provision of quality care in districts. In one such example from Lusikisiki, patients in the maternity ward in one hospital were forced to share beds.

Interventions at a district level

TAC’s prevention and treatment literacy programme provides ongoing treatment and prevention support and education. Prevention and treatment literacy practitioners provide one-on-one counselling to patients in facilities as well as group health talks and door-to-door education and support.

Prevention and treatment literacy practitioners also carry out a number of activities to support the health facilities where they are based. Activities include: pre and post-test counselling; adherence counselling and pill counting; triaging of patients; TB, HIV and cervical cancer treatment and prevention education, and defaulter tracking. In some areas prevention and treatment literacy practitioners report delivering medication to the homes of patients that are unable to reach facilities due to poor health or lack of mobility.

During the last quarter it was reported that TAC Mopani prevention and treatment literacy practitioners identified that some patients were being dispensed incorrect medication because of insufficient training of nurses now initiating treatment. Mopani prevention and treatment literacy practitioners have now reported that they are checking medication and dosage to ensure that it is correct during counselling sessions.

A number of TAC prevention and treatment practitioners as well as TAC volunteers also facilitate support groups linked to the facilities where they are based.

Finally, to improve the cleanliness of department of health facilities, TAC staff and members have carried out a number of clinic clean up campaigns. This quarter it was TAC Mopani’s turn to get out their mops and buckets, holding cleaning campaigns at Kgapane and Kremetat clinic.

HIV education in Mopani

Clinic clean-up campaign in Mopani

Targeted interventions in districts

TAC/CEGAA budget monitoring and expenditure tracking

During 2010, TAC uMgungundlovu and TAC Lusikisiki completed situational analyses in partnership with the Center for Economic Governance of AIDS in Africa (CEGAA) to inform the TAC/CEGAA Budget Monitoring and Expenditure Tracking projects. The situational analyses were carried out to provide baseline data as to what extent patients needing treatment for HIV and TB are accessing it and to assess satisfaction levels with the quality of service in district health facilities.

Focus group discussions were held with community participants to test the research questionnaire as well as to collect data for the project. Face-to-face interviews were then also conducted with community participants and government health officials.

The majority of patients surveyed were female (70% in Lusikisiki and 69% in uMgungundlovu), suggesting a higher burden of HIV on females than males and that more females then males are accessing care. 95% of patients in Lusikisiki and 49% of patients in uMgungundlovu access care from rural facilities.

The analyses revealed that 80% of patients in uMgungundlovu and 83% of patients in Lusikisiki were able to access the care that they sought during their last visit to the clinic. However 76% of patients unable to access care in uMgungundlovu reported that this was not the first time that they were unable to access treatment or care when visiting facilities. Patients and healthcare workers in both districts reported similar reasons for patients being denied care.

The main problems that patients reported for preventing access to care included: shortages of staff and particularly no doctors on site; shortages of medicine; long queues, irregular hours of facilities; and, healthcare workers taking long breaks, starting shifts late and leaving early. Patients also reported the lack of affordable transport to facilities as a challenge.

Healthcare workers reported shortages of staff, medicines and space as the main barriers preventing patients in accessing care. Healthcare workers also indicated that many patients do not have the necessary documentation or health records and there is no structure set up to share patients’ records between facilities. While healthcare workers expressed frustration at their workload and lack of support they indicated (even more strongly than patients) that they were not happy with the quality of services provided.

Lusikisiki healthcare workers also highlighted a number of challenges in procuring drugs, leading to medicines stockouts in facilities. Some facilities are operating without administrative clerks and healthcare workers are expected to order medicine supplies. Yet the shortage of staff and training on procurement management has made it difficult for healthcare workers to ensure adequate supplies of medication. Healthcare workers also complained of delays in receiving medicines or receiving less medicine than ordered, leading to stockouts.

The findings of the analyses were presented in November and December 2010 by TAC uMgungundlovu and Lusikisiki respectively to community members, healthcare workers and government stakeholders. At these public hearings, CEGAA and TAC called for the Department of Health to develop a plan of action to hire and train more health personnel to handle the workload reported at health facilities. TAC and CEGAA also recommended that an urgent system should be put in place to ensure that sufficient medicines are available at facilities.

TAC and CEGAA are following up by organising meetings with stakeholders including the department of health, district officials, district AIDS councils, the municipal health office, health care worker unions and other partners. Through these meeting TAC and CEGAA aim to pressure and support government structures to resolve issues identified through the analyses.

The full report from the CEGAA/TAC district health analysis can be downloaded here.

Queue at Lusikisiki clinic

Clinic in Lusikisiki

Door-to-door HIV counselling and testing campaign

During this quarter TAC Gert Sibande launched a door-to-door testing campaign in partnership with RE-ACTION and the Department of Health. This intervention was designed to reach groups in the community that may not come forward to be tested, or come forward far too late by actively offering HCT and follow ups in their homes.

Targeted groups include men, pregnant women, infants and immigrants. Men typically only come forward to be tested when they are sick and in the late stages of AIDS. Pregnant women and children are often tested too late to get the benefits of the updated guidelines. And foreign nationals often do not come forward mistakenly believing that they will be denied access to services.

Through this intervention, targeted groups will receive counselling and testing in their homes. If they test positive, they will be referred to their nearest facility and receive follow up visits from TAC’s team.

TAC members going door-to-door in Gert Sibande

Condom distribution and HIV education

TAC’s districts distribute condoms throughout the year. Over this quarter, TAC Ekurhuleni was particularly active in distributing condoms and spreading prevention messages. TAC Ekurhuleni distributed 270,000 condoms in informal settlements throughout the quarter. On Valentine’s Day, TAC Ekurhuleni held a condom distribution drive in partnership with Lifeline at Dayveton Mall.

The table below shows the total number of condoms distributed by all TAC offices during this period.

TAC Ekurhuleni distributing condoms

Adherence support for children and their caregivers

Within the public sector there is little psychosocial support for children with HIV and their caregivers. At the same time many children living with HIV receive no adherence counselling as it is targeted solely at their care givers. Many caregivers struggle with how they can reveal to a child that (s)he is HIV positive and sometimes children will be lead to believe they are receiving treatment for an entirely different condition.

To address the challenges that both children and caregivers face, TAC Lusikisiki held a two day adherence workshop for these groups teaching children and caregivers about adherence. Caregivers were given the opportunity to discuss challenges and share experiences. Caregivers and children were recognized for their bravery with certificates and awards.

Issues spotlighted

ARV tender and upcoming TB tender

During this quarter, government awarded tenders for the procurement of antiretroviral medicines (ARVs). With over 1 million people on treatment, South Africa has the biggest public sector ARV programme in the world. Through this tender, government was able to access lower prices for ARVs.

South Africa is now paying about R115 per patient per month for the standard triple combination of tenofovir, lamivudine and efavirenz. This is a significant price drop as under the previous tender
South Africa was paying R110 for efavirenz alone. Tenofovir prices have been reduced by 65% and efavirenz prices have been reduced by 64%. The price of abacavir, an important drug for paediatric treatment, has been halved.

One weakness of the tender, noted by SECTION27 and TAC, is that it does not allow for price reductions in the case that input costs for manufacturing the drugs are reduced. Conversely however it does allow for price hikes in cases of increasing input costs.

The major failure of the tender was that it failed to secure fixed dose combinations (FDCs) of triple therapy regimens. On 2 February 2011, Health-E reported that this failure was because the Medicines Control Council (MCC) refused to fast track the registration of FDCs prior to the finalisation of the tender. This was despite a letter sent from the HIV Clinicians Society of Southern Africa to the MCC in March 2010, urging the MCC to prioritise the registration of FDCs prior to the finalisation of the tender.

FDCs are critical not only for simplifying regimens but also for improving adherence and patient outcomes. Slow registration by the MCC has become a barrier to improving healthcare delivery in the country.

South Africa has now put out its tender for TB medicines for the period of August 2011 through July 2013. During the previous tender, suppliers were unable to provide adequate supplies of TB medicines leading to stock-outs of critical TB medicines and causing government to issue an interim tender. Through the current tender, government must ensure that there are adequate supplies of TB medicines to end stock-outs.

It has also been revealed in a report issued by Medicins Sans Frontieres that South Africa is currently paying far too much for drug resistant TB treatment. South Africa is paying three times more than is paid for by Medicines Sans Frontieres for the equivalent drug resistant TB medicines.

The Department of Health must use the current tender to procure medicines at the lowest possible prices and to ensure that there is adequate supply to meet the need. The MCC must not act as a barrier, as it did with the ARV tender, by delaying the registration of critical medicines.

On 2 February 2011, the Advertising Standards Authority of Southern Africa (ASASA) ruled that e-tv must cease airing commercials by the church Christ Embassy promoting faith as a means to cure HIV and a range of other diseases. This ruling came following a long running complaint by TAC, issued in November 2009.

TAC originally launched the complaint against Christ Embassy after receiving a report that a woman with extremely drug resistant TB, who had made significant progress on her medical treatment, stopped taking her medicines because she believed Christ Embassy had cured her. She consequently became ill with XDR TB again and died but only after transmitting XDR TB to her children.

TAC made the complaint because the claim by Christ Embassy to cure HIV and other conditions is in violation of Appendix F of the ASASA code. Appendix F prohibits offering products to treat a range of diseases including HIV if the products have not been registered by the Medicines Control Council.

ASASA initially dismissed TAC’s complaint, ruling in June 2010 that the content was sponsored programming which meant ASASA did not hold jurisdiction over its content. TAC lodged an appeal against this ruling, following which ASASA ruled on 2 February that e-tv must cease airing the commercials.

The 2 February 2010 ruling:

• clarified that the word product in appendix F of the advertising code is defined as including goods, services, activities and facilities. The ruling states that Christ Embassy was clearly offering a healing service; and,
• established that whether material is an advert is an objective test defined by the ASASA code and is independent of the medium in which the material appeared or the contract between the advertiser and the medium. Christ Embassy's argument that their programme was not an advert was dismissed.

Christ Embassy has lodged an appeal against the 2 February ruling and TAC will continue to fight the appeal.

The Christ Embassy case is one example of many cases of untested and potentially harmful treatments and cures that are promoted in South Africa. In an effort to shed light on this problem, and to expose fake medical cures, TAC and Community Media Trust launched the website Quackdown on 5 February 2011. The site is now live containing a database of quacks and publishing stories weekly on quackery.

Gender based violence

Between December 2010 and February 2011, TAC’s gender based violence (GBV) campaign focussed on mobilising communities against rape of minors and drawing attention to the negligence of the courts in prosecuting GBV cases. TAC Khayelitsha also worked to build internal systems to strengthen its advocacy around GBV.

TAC Ekurhuleni, Lusikisiki and uMgungundlovu mobilised against rape of minors in response to the high rates of these crimes in their communities. It is estimated that 40% of rape victims in South Africa are minors.

TAC Ekurhuleni responded to the tragic rape and murder of a 9 year old girl in Thokoza, an informal settlement in Johannesburg. TAC organised a march to the Thokoza police station on 10 December. Community members and children from local crèches participated in the event expressing outrage against the rape of children and infants.

In the rural village of Ngobozana, near Lusikisiki, TAC responded to a report that a 5 year old girl was raped. TAC Lusikisiki assisted the young girl in accessing post-exposure prophylaxis and legal support. They then carried out a door-to-door campaign in the area to educate the community about the rape of minors and to mobilise the community to call for perpetrators to be brought to justice.

TAC uMgungundlovu is currently monitoring 4 cases of GBV in the district through attending court hearings, consulting with investigating officers and community members, and organising marches. Three of these cases were committed against minors.

By mobilising around GBV cases and trials, TAC aims to provide support to survivors and families and to ensure timely access to justice. Seeking justice for gender based violence in South Africa can be a traumatising and sometimes impossible process. According to People Opposing Women Abuse (POWA) only 10% of cases reported result in successful convictions.

Since its inception, TAC has held numerous demonstrations against the negligence of the courts in prosecuting GBV cases. To date, one of the cases that TAC Khayelitsha has been monitoring, the case of Zoliswa Nkonyana, has been delayed 35 times, dragging on for five years.

Given the ongoing challenges faced by communities in accessing justice, in January TAC Khayelitsha created a GBV task team to strengthen TAC’s advocacy through improving its system of monitoring and collecting data on GBV cases.

The GBV task team's primary responsibility is to gather information about cases. Specifically, the task team created an online database of eight major rape and murder cases it is following in the district. The database includes information about the status of each case, dates of upcoming hearings, and names of prosecutors and magistrates involved in the cases.

Task team members are also attending every hearing in these priority cases and meeting regularly with prosecutors involved in these cases. While some meetings are confrontational, task team members have also built relationships with prosecutors, who regularly update TAC about the cases.

In addition to meeting with prosecutors, task team members have also met with police investigators to learn more about the status of investigations and the role that the police are playing in producing evidence for trial.

During this period, the GBV task team also reached out to the Women’s Legal Centre and Legal Resources Centre to educate TAC members about the court system and how advocates can more effectively respond to GBV cases. Trainings for TAC members have been scheduled for the next quarter.